Provider Demographics
NPI:1538615067
Name:FALLIS, JESSE (LPC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FALLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5655 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-9382
Mailing Address - Country:US
Mailing Address - Phone:318-218-2360
Mailing Address - Fax:
Practice Address - Street 1:5655 N LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-9382
Practice Address - Country:US
Practice Address - Phone:318-218-2360
Practice Address - Fax:650-870-2727
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA7191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7191OtherLICENSED PROFESSIONAL COUNSELOR
886921OtherNATIONAL BOARD CERTIFIED COUNSELORS